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What’s new in and Toxinology (2020)

Some of the new information and major changes included in the Toxicology and Toxinology guidelines in eTG complete.

The Toxicology and Toxinology guidelines have been extensively revised • Risk assessment—toxic dose and toxic concentration (if and expanded. The updated treatment recommendations are based available); clinical presentation; key investigations on available evidence and the consensus of our expert group. The guidelines are targeted towards hospital doctors, especially emergency • Treatment—resuscitation, including interventions for airway, department staff, as well as primary care providers (first responders, breathing and circulation; decontamination and enhanced general practitioners, rural and remote practitioners) and elimination techniques; specific treatments (eg , information specialists. sedation, seizure control) • Observation and patient disposition—optimal duration What is covered in Toxicology and Toxinology? for observation; advice for admission to hospital; special considerations for discharge. The guidelines provide practical advice on managing a wide range of , exposures to toxic agents and envenomings. Toxicology and Throughout the guidelines, advice on risk assessment and treatment Toxinology now comprises: in specific monographs often links back to the general approach • 14 topics on the general approach to managing and toxidrome topics. Common interventions in the management of poisonings that are covered in the general topics include: • 7 topics on specific toxidromes (toxic syndromes) • 117 monographs about individual drug poisonings, envenomings • Inotropic support: first-line therapy, including adrenaline and exposures to other toxic agents. (epinephrine) and noradrenaline (norepinephrine) • Inotropic support: high-dose insulin euglycaemia therapy Dozens of new monographs have been added to encompass a larger (HIET), which may be recommended for second-line inotropic number of rare but highly toxic drugs and other agents (eg Amanita therapy phalloides , Button battery ingestion, specific herbicide poisonings including Paraquat, Glyphosate and Chlorophenoxy • Cooling for drug-associated hyperthermia, depending on herbicides). availability, practicality and expertise

Other new poisoning monographs include Apixaban and rivaroxaban, • Decontamination for poisonings, including detailed discussion Dabigatran, Buprenorphine, Cocaine, Insecticides, , Local on the risks of harm versus benefit of gastrointestinal anaesthetics, and Monoamine oxidase inhibitors. Some topics have decontamination with activated charcoal been split to address the different treatments for acute poisoning versus • Sedation in poisoning, which may require higher than usual chronic accumulation (eg Digoxin, Lithium). doses Some drug classes include both a general monograph for the class, and • Seizure control in poisoning, which may require antiepileptic specific monographs for individual drugs with specific issues in poisoning. drugs other than benzodiazepines or For example: • Multiple-dose activated charcoal or extracorporeal elimination • Antidiabetic drug poisoning (general), plus specific monographs for techniques (including haemodialysis). Insulin, Metformin and Sulfonylurea poisonings Flowcharts to aid in clinical decision-making have been updated • Antiepileptic drug poisoning (general), plus specific monographs based on the most recent evidence. Flowcharts available as printable for , Benzodiazepines, and figures and include: oxcarbazepine, Lamotrigine, Phenytoin, Pregabalin and gabapentin, Sodium valproate, Tiagabine and Topiramate poisonings • Management flowchart for a single ingestion of 10 grams (or 200 mg/kg in patients under 50 kg) or more of immediate- • Antipsychotic drug poisoning (general), plus specific monographs release for Amisulpride, Clozapine, Olanzapine and Quetiapine poisonings • Management flowchart for modified-release paracetamol • Hydrocarbon poisoning (general), plus specific monographs for poisoning Ingestion, Inhalation and Injection of hydrocarbons • Summary of the acute management of suspected snake bite • Novel psychoactive drug poisoning (introduction), plus specific in Australia. monographs for Novel stimulant, Novel hallucinogen and Synthetic cannabinoid receptor agonist poisonings Is Toxicology and Toxinology evidence based? • Poisoning from plants (introduction), plus eight specific monographs for various plant . Many of the poisonings, envenomings and other exposures covered in the guideline are uncommon, and evidence in this field is often limited. How do I use Toxicology and Toxinology? The guidelines are based on the available evidence supported by the consensus of the expert group. Every monograph includes evidence- The guidelines include content on the general approach to poisonings, based treatment recommendations, including children’s doses (if and specific toxidromes (eg Cholinergic toxidrome, Serotonergic available) and maximum doses. toxidrome), followed by the grouped and individual poisoning monographs, listed alphabetically. Specific recommendations for pregnant or breastfeeding women are not included because management for poisoning in this group is no Most of the poisoning monographs have the following consistent different to the general population. structure for ease of navigation: • Management overview—drug(s)/agent(s) and preparations available; salient points about and urgency of management; key management priorities and pitfalls What practice-changing updates should I be aware of in • Red-back Toxicology and Toxinology? Red-back spider antivenom is not recommended. Analgesia is the mainstay of therapy. •

It is now recommended to measure alanine amino- • Major box jellyfish Chironex( fleckeri species) sting transferase (ALT) concentrations in addition to serum Intramuscular administration of box jellyfish antivenom is paracetamol concentrations in all patients, at least not recommended. Intravenous administration in hospital is 4 hours after ingestion. recommended. Changes to recommendations for as an for paracetamol poisoning include: • Button battery ingestion • a standard two-bag (20-hour) acetylcysteine protocol If there is any suggestion of a button battery ingestion, to replace the former three-bag protocol a time-critical X-ray of the neck, chest and abdomen is • varying acetylcysteine protocols for poisonings due urgently recommended, as well as referral for endoscopic to immediate-release, liquid, and modified-release removal if a battery is seen. paracetamol preparations • recommendation of high-dose (double-dose) • Digoxin poisoning acetylcysteine in the second infusion for high risk Titrated digoxin-specific immune antibody fragments (digoxin poisonings and for serum paracetamol concentrations immune Fab) is now recommended for acute digoxin that are more than double the paracetamol treatment poisoning with life-threatening hyperkalaemia or arrhythmia, nomogram line unless the patient is in cardiac arrest. Lower doses, also • addition of specific treatment for unintentional titrated, are used for the same complications in patients paracetamol poisonings (also known as repeated with chronic digoxin accumulation. supratherapeutic ingestion [RSTI]) • recommendation of extended acetylcysteine therapy • Colchicine poisoning for patients with evidence of . Updated treatment recommendations rely on the dose of colchicine ingested to guide interventions, including • Acetylcysteine therapy for hepatoprotection in other gastrointestinal decontamination and enhanced elimination poisonings using activated charcoal. Patients at higher risk of Acetylcysteine is recommended for hepatoprotection in a developing colchicine toxicity have a lower dose threshold standard two-bag protocol for: for these interventions. • Amanita phalloides mushroom poisoning • • Gastrointestinal decontamination • paraquat poisoning Activated charcoal for gastrointestinal decontamination can • some hydrocarbon poisonings, including benzene, be used to treat significant overdoses (after assessing the carbon tetrachloride and chloroform risk of harm versus benefit): • some essential oil poisonings, including clove oil • up to 2 hours after ingestion of immediate-release and pennyroyal oil. preparations • 4 hours or more after ingestion of modified-release • Snake bite preparations. The critical steps in the management of snake bite in Whole bowel irrigation can be considered: Australia are: • up to 4 hours after ingestion of significantly toxic drugs • determine if the patient has evidence of systemic (eg , modified-release preparations) envenoming • for ‘body packers’ and ‘body stuffers’ (concealed illicit • if so, determine if antivenom is indicated drugs). • if so, determine the snake group(s) likely to be responsible for the bite, to guide the choice of • Maximum doses antivenom(s). Specific maximum total doses have been added for some These decisions are supported by a new flowchart of drugs; for example: management of suspected snake bite in Australia. • the maximum total dose of intravenous sodium bicarbonate 8.4% for serum alkalinisation is 6 mmol/kg In most places, treatment of snake bite comprises • the maximum total dose of 10% for combinations of single-dose monovalent antivenoms cardiac stabilisation in hyperkalaemia is 60 mL. (eg tiger snake plus brown snake antivenom). Testing with a detection kit is no longer recommended.

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08/2020